2026 CODAC Benefit Summaries and Carrier Flyers

If a Covered Person chooses to use a Personal Representative, the Covered Person must submit proper documentation to the Plan stating the following: the name of the Personal Representative, the date and duration of the appointment, and any other pertinent information. In addition, the Covered Person must agree to grant his or her Personal Representative access to his or her Protected Health Information. The Covered Person should contact the Claim Administrator to obtain the proper forms. All forms must be signed by the Covered Person in order to be considered official.

ASSIGNMENT OF BENEFITS

The term “Assignment of Benefits” shall mean an arrangement whereby the Covered Person assigns his or her right to seek and receive payment from the Plan for eligible Covered Expenses to a Provider, in strict accordance with the conditions and limitations of such rights provided under the terms of this Plan.

Conditions and Limitations of an Assignment of Benefits:

1. The validity of an Assignment of Benefits by a Covered Person to a Provider is limited by the terms of this Plan. An Assignment of Benefits is considered valid on the condition that Provider accepts the payment received from the Plan as payment in full for Covered Expenses for services, supplies and/or treatment rendered. This amount does not include any cost sharing amounts (i.e. copayments, deductibles, or coinsurance), or charges for non-covered services; the Provider may bill the Covered Person directly for these amounts. 2. An Assignment of Benefits cannot be inferred, implied, or transferred. An Assignment of Benefits must be made by the Covered Person to the Provider directly through a valid written instrument that is signed and dated by the Covered Person. terms of the Plan, including initiating an internal or external appeal of an adverse benefit determination in accordance with the terms of the Plan. Notwithstanding the foregoing, the Covered Person does not, under any circumstances, have the right to assign to any Provider (or their representative) through an Assignment of Benefits any right to initiate any cause of action against the Plan that the Covered Person them self may be afforded under applicable law. This includes, but is not limited to, any right to bring suit as such is afforded to Covered Persons under ERISA section 502(a). The assignment of any right to initiate suit against the Plan to a Provider is strictly prohibited. 3. Unless specifically prohibited by a Covered Person, a Provider with a valid Assignment of Benefits may exhaust, on behalf of the Covered Person, any administrative remedies available under the

4. An Assignment of Benefits does not grant the Provider any rights other than those specifically set forth herein.

5. The Plan Administrator may disregard an Assignment of Benefits in its discretion and continue to treat the Covered Person as the sole recipient of the benefits available under the terms of the Plan.

6. An Assignment of Benefits by a Covered Person to a Provider will not constitute the appointment of a Personal Representative.

By submitting a claim to the Plan and accepting payment by the Plan, the Provider is expressly agreeing to the foregoing conditions and limitations of an Assignment of Benefits in addition to the terms of the Plan. The Provider further agrees that the payments received constitute an ‘accord and satisfaction’ and payment in full for the Covered Expenses for services, supplies and/or treatment rendered. The Provider agrees that the conditions and limitations of an Assignment of Benefits as set forth herein shall supersede any previous terms and/or agreements. The Provider agrees to the specific condition that the patient not be balance billed for any amount beyond applicable cost sharing amounts (i.e. Co-pays, Deductibles, or Plan Participation), or charges for non-covered services; the Provider may bill the Covered Person directly for these amounts.

-98-

7670-00-415125